Thank you, and I'd like to thank John Kelly for inviting me to be a part of this panel. So we've been asked to talk about the reverse as the only real option, and are you kidding me? I mean, there are different options for different situations. I think the message you've heard from almost everybody is don't be a one-trick pony. We've all used a lot of these different things, but there are some guidelines. Size matters and age matters, and when we look at the size of the tears, there have been multiple studies that have shown that the larger the tear, the higher the re-tear rate or the higher the non-healing rate. And this study out of Australia, the older you are, the more likely you're going to have a re-tear. Now, you've just seen all five of these great arthroscopists show us all kinds of these tricks, and I've done all these tricks and may try that balloon. If you have a patient who is less than 60 years old, has an acute mobile tear, I would do all of these, and I'm going to try the balloon. But what do you do if you have a patient who's over 60 years old, he's got arthritis, he wants to return to a high-level activity, are you going to be able to tell him that he can do all those things with the balloon in his shoulder? And what are the long-term results from all those different things? So what is the indication for a reverse? Well, one of the indications is a massive rotator cuff tear that we're talking about today. My indication, though, is when the patient can't raise his arm any higher than the tattooed lady can raise her leg, then it's time to do a reverse. So what's the activity following these reverses? Well, this is a study by Quinn Throckmorton out of Campbell Clinic, shows very high return to high-demand activities, and his advice was that the concern about activity level with the reverse may be unwarranted. This is a study by Sperling out of the Mayo Clinic, and in younger patients, and they found a 90% survival rate and no difference in complications. And then most recently, Mark Frankel with his group just reported on their 10-year survival. So at 10-year survival with a reverse shoulder replacement, they had 91% survivorship, only two revisions and one fracture, and there was no diminishment in scores as time went on. And that really mimics my results. So I noticed when I looked at my reverses versus the anatomics, faster recovery, equal return to high-level activities, include golf, tennis, swimming, weightlifting, and no radiographic or clinical failures in primaries at 10 years. And then we'll look at a cohort that I've been following, so a five-year follow-up. These were done between 2011, 2013. High constant scores, high return to function, and high range of motion. And I had low complications, primarily acromial stress fractures, a few instability cases, and only two revisions and no deep infections. And 73% were able to return to very high-level activities. So why do these patients do so well? Well, one, I'm a high-volume shoulder surgeon, so I do over 200 arthroplasties a year, but also do over 200 cuffs a year. I use a lateral offset and a 135-degree neck shaft angle, and most of the companies now have this option available to you, and I think, for me, it works better and there's lower complications, especially with notching. And I give them a detailed home exercise program, which they do it five times a day, so they get 35 sessions of physical therapy, and they follow my program. The surgery is very reproducible, and I give them handouts. We have videos on the website to show them what exercises I want them to do and how they can follow this plan along. And over 80% do it all on their own, they don't go to formal physical therapy. But you shouldn't believe me that they return to high activity, I should have to show you. So this guy has returned to a five handicap. This guy lifts weights, even doing flies, and he's over 70 years old. Even the ladies, she's doing planks. This guy, that's his range of motion at one year, and then on the right is range of motion at five years. And I want to show you all the range of motion, but at five years, he's doing push-ups on his reverse. And Scott, can you do push-ups on a balloon? I don't know. And then he wasn't tired, so he went the other way to do some more. This guy's swimming, so I want you to tell me, which side did I do the reverse on? So everybody can do breaststroke, but now he's going to turn around and do overhand crawl. So I think you can return to high activity, and you really can't fully regain your range of motion. This guy has a video on my website. He's admonishing the patients that this is what they should be doing. And this is six months, and I'm not going to show the whole thing runs about 10 minutes, but now he's going to do some flies. So this is the type of patient I get. This guy's had two reverses. He's showing us his basketball prowess and throwing a football. So for me, it's a no-brainer. He got a massive tear, someone older than 60 years old, or he has arthritis. Think about what's going to give him the best long-term follow-up for the rest of his life. So do it for those patients, do it when all these previously advertised gimmicks fail, and do a reverse. Thank you very much.

rotator cuff tears

treatment options

tear size

patient age

reverse shoulder replacements